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Application <br />– FOR – <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />Mailing Address: %_ Building, South Bend , Indiana 46601 <br />Phone: 574 -235 -9798 • Fax: 574 -235 -9578 • Email: historic@michiana.org <br />Website: http: / /communitymichiana.org /historic/ <br />A Certified Local Government <br />OFFICE USE ONLY » »» DO NOT COMPLETE ANY ENTRIES CONTAINED IiV TIHS » »» OFFICE USE ONLY <br />Date Received AZ4 4o1'�r Application Number ��'L - cy q <br />Past Reviews: ❑ YES (Date of Last Renew) 2 "O <br />Staff Approval authorized by: �>�'. Title: _,,( �� ' • ��� <br />Historic Commission Review Date: A <br />Local Landmark M<o c al Historic District (Name) -uJd� f <br />National Landmark [j National Register District (Name) <br />Certificate of Appropriateness: <br />F] Denied F] Tabled F� Sent To Committee [�pproved and Issued <br />ATE <br />Address of Property for proposed work: O0 R I a "�- k e n 5 r r,! iI – 0/i ��L 1 yAp <br />Street Number and Street Name <br />Name of Property Owner(s) (Please Print) <br />Address of Property Owner(s): Ca t. U r 'r, <br />Contractor(s) Name: —jg-t" IF }' d s i. 'r <br />I <br />Contract Company Name: <br />Contractor Address: -114-1 At x% V 4 S." <br />City: ' if 6 !qd 6 !q Phone: _4:7 <br />Current Use of Building: ''�' ` <br />(Single Family — Multi-Family — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work- [] In -kind ZLandscape <br />E] New [:] Replacement (not in -kind) Demolition <br />(more than one box nury be checked) <br />RR •� <br />Description of Proposed Work: lr W N x� �1 {'�• o L t " <br />- _R �o c �C r U �-N�Sr g <br />fit= U it w °, = 1 r Ak .ti A + WA -A T r� p c , � lt�ESN i va <br />�l e of 5 NC R �� ` �14 414 c 4 - ty' c' ,� a t �rv�d� <br />_— <br />A <br />/Contractor: dFax: e-mail <br />(This ofce will espond with only one designee) <br />and /or / /_ n <br />Signature of O ner "'Signature of Contractor <br />VhWl <br />— APPLICATION REQLUREMENTS ARE LISTED ON REVERSE SIDE — <br />